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A small number of doctors are linked to large numbers of malpractice claims, according to a new study—but what are the implications of these findings, and how do we view them in perspective? HRMR reports.

A substantial share of all malpractice claims in the US is attributable to a small number of physicians, according to a study led by researchers at Stanford University and the University of Melbourne published on January 28 in The New England Journal of Medicine.

The team found that just 1 percent of practicing physicians accounted for 32 percent of paid malpractice claims over a decade. The study also found that claim-prone physicians had a number of distinctive characteristics.

“Our findings highlight the size of a problem that is recognized but not well understood—namely, the extent to which malpractice claims are concentrated among a relatively small group of physicians,” says the lead author of the study David Studdert, professor of medicine and of law at Stanford.

“The fact that these ‘frequent flyers’ looked quite different from their colleagues, in terms of specialty, gender, age and several other characteristics, was the most exciting finding. It suggests that it may be possible to identify high-risk physicians before they accumulate troubling track records, and then do something to stop that happening.

“The degree to which the claims were concentrated among a small group of physicians was really striking,” adds Studdert, an expert in the fields of health law and empirical legal research who is also a core faculty member at Stanford Health Policy.

“We found greater concentration than previous—albeit much smaller—studies have. We were also surprised that a physician’s history of prior paid claims was such a strong predictor of his or her future risks.”

Detailed analysis

The researchers analyzed information from the US National Practitioner Data Bank (NPDB), a data repository established by Congress in 1986 to improve healthcare quality. Their study covered 66,426 malpractice claims paid against 54,099 physicians between January 2005 and December 2014.

“The degree to which the claims were concentrated among a small group of physicians was really striking." David Studdert

Almost one-third of the claims related to patient deaths; another 54 percent related to serious physical injury. Only 3 percent of the claims were litigated to verdicts for the plaintiff. The remainder resulted in out-of-court settlements. Settlements and court-ordered payments averaged $371,054.

“The concentration of malpractice claims among physicians we observed is larger than has been found in the few previous studies that have looked at this distributional question,” says Dr Michelle Mello, a co-author of the study and professor of law and of health research and policy at Stanford.

“It’s difficult to say why that is,” Mello adds. “The earlier estimates come from studies of single insurers or single states, whereas ours is national in scope. Also, the earlier numbers are more than 25 years old now, and claim-prone physicians may be a bigger problem today than they were then.”

The authors recommend that all institutions that handle large numbers of patient complaints and claims develop a greater awareness of how these events are distributed among clinicians.

“In our experience, few do,” they write in the paper. “With notable exceptions, fewer still systematically identify and intervene with practitioners who are at high risk for future claims.”

Examining the claims history

The most important predictor of incurring repeated claims was a physician’s claim history. Compared to physicians with only one prior paid claim, physicians who had two paid claims had almost twice the risk of another one; physicians with three paid claims had three times the risk of recurrence; and physicians with six or more paid claims had more than 12 times the risk of recurrence.

“Risk also varied widely according to specialty,” the authors note. “As compared with the risk of recurrence among internal medicine physicians, the risk of recurrence was approximately double among neurosurgeons, orthopedic surgeons, general surgeons, plastic surgeons and obstetrician-gynecologists.”

The lowest risks of recurrence occurred among psychiatrists and pediatricians.

Male physicians had a 40 percent higher risk of recurrence than female physicians, and the risk of recurrence among physicians younger than 35 was about one-third the risk among their older colleagues, the study found.

“If it turns out to be feasible to predict accurately which physicians are going to become claim-prone, that is something liability insurers and hospitals would be very interested in doing,” Studdert says.

Putting it in perspective

The Physicians Insurers Association of America (PIAA) has already responded to the findings, saying it is keen to view them in perspective. “We commend the efforts of these researchers to explore ways to improve patient safety and the delivery of medical care,” says PIAA president and CEO Brian Atchinson.

“We believe, however, that there are many variables that play a role in the distribution of miscellaneous professional liability (MPL) claims that the study fails to address. In doing so, it leaves a false impression that those healthcare professionals who are subject to more lawsuits are providing negligent care.

“We know that certain specialties—such as neurosurgery, obstetrics and gynecology, and others—have been linked with a higher frequency of claims. These doctors experience more claims because of the risk associated with their particular specialty, and not because they are inherently prone to making mistakes more often than their colleagues.

“These physicians have chosen to take on some of the highest risks and the most complicated cases. For this reason, they may be more vulnerable to suboptimal outcome, stemming from the very nature of their advanced level of practice.”

PIAA’s vice president of research and risk management, P. Divya Parikh, adds that the source of the data used in the study also affects its rigor. “The NPDB, while accurate in the information it collects, is unable to capture complete data on MPL claims. This underreporting to the NPDB limits the conclusions that one can draw from using such a dataset.”

Parikh also notes that studies have shown that all physicians are likely to be named in at least one medical liability claim during the course of their careers—with some subject to more based on their specialty.

“This study hasn’t really revealed anything we didn’t already know. We believe the findings of this study are not conclusive, so we encourage the continued exploration of all of the factors that can help in advancing the provision of safe, quality healthcare.”

While the jury is still out on how to view the findings and what possible actions to take as a result of them, Studdert emphasizes that he hopes the study will be a positive force for improving quality and safety.

“One option is to kick out the high-risk clinicians, essentially making them someone else’s problem, but our hope is that the knowledge would be used in a more constructive way, to target measures such as peer counseling, retraining, and enhanced supervision. These are interventions that have real potential both to protect patients and to reduce litigation risks.”

As for follow-on work, the researchers are now trying to make more progress on the challenge of developing statistical methods that allow them to predict future claims reliably at the individual clinician level.

“This is of great interest to us. It’s the part of the project with the most potential for improving the safety of care patients receive,” says Studdert.

The New England Journal of Medicine, Medical Malpractice, David Studdert, Dr Michelle Mello, Stanford, US